Foundations Exam 1: Chapter 15, 16 & 20

"I think there is a better way to handle this."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

The nurse gently strokes the baby's cheek to facilitate breastfeeding.

A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Which example of nursing care achieves this goal?

By 18AUG2015, client will demonstrate improved motion in left arm.

Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?

"Let us know if we can answer any further questions after you obtain your second opinion."

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

Ensure that the client's name appears on all pages.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Orientation phase

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Quality improvement Continuous quality improvement Total quality improvement

A new graduate nurse is working in a hospital that is utilizing a program to continuously improve every process in every department of the facility. What processes will the graduate determine is being utilized? Select all that apply

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

Progress notes

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

Facilitates quality Serves as a financial record Supports decision analysis Assists with clinical research

A nurse is preparing an educational session on the purpose of documentation in health care records. Which topics should the nurse include in the education session? Select all that apply.

identifying risks and ensuring future safety for clients

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

Calling the client information desk to find out the room number of the family member

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

"Why did the health care provider prescribe this medication for you?"

The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions?

Incident report

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Respiratory assessment

The nurse is looking for information to care for a client. Which information would the nurse be unable to locate in the client care summary or kardex?

Orientation phase

The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship?

Ask the client if information can be given to the parent.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?